Crook in the Bush: Why Broadband matters to health outcomes in rural and remote Australia

Martin Laverty, CEO of the Royal Flying Doctor Service

The Royal Flying Doctor Service (RFDS) is a health charity established almost 90 years ago. We are not experts in broadband, but it is increasingly becoming a significant part of the development of the Flying Doctor services.

I want to introduce to you one of our patients, Gene Hildebrand, who indeed is lucky to be alive. He lives between Alice Springs and nowhere; a few hours’ drive from Alice Springs. Before Christmas time he felt the early symptoms of a heart attack and he was lucky enough to get himself into Alice Springs safely but his condition was such that a decision was made to transport him to Adelaide.


Enter the Royal Flying Doctor Service.

He had his first heart failure; his first death, at our facility on the runway at Alice Springs. During the course of his three hour journey into Adelaide, Gene would die 54 times. Each time his heart stopped, his heart was restarted by a nurse; one of our long serving flight nurses who was on board for what she thought would be a regular, routine trip. Whilst Gene has set a new inflight record, this is not an unusual occurrence for us. People experience these extraordinary health impacts whilst they are in the air in our care. Gene is in part alive today because of the technology that is available within our aircrafts. They are not big machines. They are small aircrafts, and if configured for commercial transport they might fit 10-12 people, but when they are equipped with two stretchers and with medical equipment the environment becomes quite tight. You can appreciate that with space as a premium we want to see technology that is available in that environment that is light weight and able to be used for multiple purposes. Part of the componentry is an electrocardiograph machine, an ECG. It was the ECG that was monitoring Gene during his flight that was essential for the nurse on board to be able to provide the expert care that she did, and it is because of her and the pilot that was supporting Gene in his journey, that he is alive. The ECG machine and other equipment had a whole lot to do with it.

What if in the future we didn’t have to spend roughly fifteen thousand dollars for each ECG machine that weighs about 3.5 kilos within our aircraft? What if we could get something a whole lot cheaper — something that was lightweight? Today I have on my phone an app that literally costs 99 cents to download and it is going to take my ECG while I’m writing this. On the back of the phone, is a little clip-on (it cost me 18 dollars in the United States). By connecting and asking it to record it takes my ECG, and I am then able to email this ECG to any point in the world. If I was in a remote part of Australia I might be emailing it to the RFDS in advance of the aircraft arriving to give the doctor a diagnosis prior to their arrival. My ECG is now recorded and very pleasingly it tells me that I have a normal heart rate.

The technology that was once fifteen thousand dollars, that needed to be equipped in each of our aircraft (and we have 66 of them) is now available for less than twenty dollars. It is not yet in service within the Royal Flying Doctors, and it won’t be for some time. You can appreciate this technology operates in the cloud, if we don’t have sufficient access to the cloud across every inch of Australia, with the security and stability that we need it, we can’t yet rely on this technology. It’s cheaper and more effective and gives stunning opportunity to give clinical care to the point that it’s needed faster than we are able to at present. But we still operate in an environment where broadband, if it exists, is patchy and unreliable. We need to get the National Broadband Network working in this country – not for the point of arguing about the type of broadband that’s available and how its delivered — but rather that people’s lives can be saved by the opportunity of the technology that sits ahead.

In South Australia, over the course of the last fourteen years, a study has been undertaken that looks at the disparity in heart health outcomes between city and bush. It says that someone who lives in remote or rural South Australia is about 25% more likely to die from a heart attack than someone who lives in the city. A trial that’s been operating in the ten years up to 2014 with the use of remote consultation, which in the old school definition was a cardiologist in Adelaide with a fax machine and a telephone, communicating to small rural hospitals in parts of South Australia. The trial was effectively able to close the disparity and the 25% gap in the risk of death through heart attack, by having a cardiologist consult remotely via fax about the type of intervention that should be provided. In South Australia today, because of the fax machine and the school clinicians that sit either side of it, there is no difference in the risk of heart attack death in rural South Australia to metropolitan South Australia.

Sadly across the nation, the risk in country areas on a national average is still close to 30% higher than it is in the city. Therefore, if you are going to have a heart attack; have it in a city area. The closest you can be to a catheter lab to be able to have that rapid access to the support you need is key. But what the trial in South Australia said, by using old school technology in this case, is that you are able to connect a clinician from part A through to part B and through the most basic interventions, remove the disparity in health outcomes that exist as a consequence of distance.

The RFDS works to overcome the barrier to health outcomes that exist because of distance across this vast land. In the past we did this only through aircraft, but times are changing, and in the future you will see us more interested in the way broadband can help us overcome these barriers.

It almost doesn’t make sense to live in the bush – your health is better if you live in the city. Country people die two and a half years earlier than someone that lives in the city. On average we see that there is a 35% higher death rate in remote parts of Australia than there are in the city. Country people see doctors at half the rate than people who live in the city. They see specialists at a third of the rate and mental health professionals at a fifth of the rate.

This correlation between poor health outcomes in the bush and access to health services is well established. Some could reasonably say people in the city are seeing doctors too often and maybe an average of ten visits per year for a city resident is a little high. The suggestion though that people in the country have sufficient access to health care just doesn’t play out when you look at these differences in illness and life expectancy that exists in this extraordinary divide.

One of the ways in which the Flying Doctor started, and its first embrace of technology was at the time when the school of the air was invented by John Flynn — piggybacking the introduction of radio telehealth. Telehealth was in fact invented in Australia. It was invented by the Royal Flying Doctor Service. It was invented as a response to the reality that people in the bush are never going to have the same access to health care services as people in the city and there isn’t a possibility for a doctor to be put on every country town street corner. Instead it has recognised the other options to address this issue.

This year we will consult about 100,000 rural and remote Australians over the telephone and provide them with tele-health. It’s a distinctly different service to that which operates in city areas. Whilst you may have yourself had the experience of using an after-hours GP line, in the bush you don’t have the option of a referral to a suburban GP practice or an Emergency Department. Of the 100,000 calls that we will take in this calendar year, where a GP consults with a patient over the phone, 98% percent of those are going to be concluded. The GP, with the patient, will solve over the phone 98% of the matters presented. It is a very different type of service and it has risen out of having almost no other choice. We have the video conferencing platforms; we know the technology such as being able to take and send an ECG exists, but we are not yet in a position as a health care provider to make that step to relying on video conferencing despite the evidence of that efficacy that says the clinical outcome is far superior and that we will be able to much better inform the diagnosis that the doctor makes. We are not yet able to do it because the capability of the broadband in the areas in which we work (and our patients live) is not yet consistent or stable to support such services.

The research and policy unit of the RFDS recently released evidence about the disparity in accidents and injuries that exist between city and bush. You’re two times more likely to be injured if you live in country Australia than if in the city. You’re four times more likely to die in a motor vehicle accident on a country road than in a city area, if you work on farms or in the agricultural sector you’re nine times more likely to be injured than in the average of all other industries combined. Is the risk greater in the bush? Certainly the Occupational Health and Safety laws are the same in city and country – so what opportunity do we see to prevent these accidents and injuries from occurring?

Per hundred thousand people, about five deaths occur on Australian roads each year. In the United Kingdom that figure is only two and a half — so Australia’s road toll is twice as bad as in the UK. It is arguable that the UK is a very different country, smaller areas, larger population, safer roads, but what the UK has been managing far better than in Australia is the application of technologies to monitor driver behaviours, to monitor roads that need improvement, to monitor risk spots than Australia is yet been able to come to terms with. The data exists but it is not yet in a system that can be used in real time to provide the types of interventions to prevent the high prevalence of road death that we see and respond to as the Flying Doctor in country Australia. One of the reasons is we don’t yet have the broadband system in country Australia that allows us to take advantage of the knowledge and interventions that are available to save peoples lives, that are so effectively being used in the United Kingdom and other parts of the world.

If we look briefly at the patient group that we spend majority of our time with, about 150 thousand Aboriginal and Torres Strait Islanders will be served by the RFDS this year and our data indicates that the main reasons we dispatch an aircraft to respond to a call from a patient to receive care who is of Aboriginal and Torres Strait Islander descent is in response to Injury, Circulatory system and Respiratory system illnesses. Ten years ago we didn’t capture this type of data because there weren’t the systems in place to operate across the 7.5 million square kms which our service operates across for our doctors and nurses to be able to record data to be able use it effectively. Now, each of our practitioners have the tools of trade including an IPad to be able to record patient data to inform what they are responding to and what it tells us.

If we just take Aboriginal and Torres Strait Islander patients and look specifically at respiratory illness you’ll see that the majority of our work is for infants aged less than one. Information that we just didn’t have years ago and the emergence of our ability to network our data collection has informed the services that we are now planning. But we are now at the point that if broadband works efficiently we’d be able to turn this into real time intelligence such that as an outbreak of influenza or pneumonia in babies in a particular Aboriginal community might be occurring we would be able to spot it. Our response today, because we can’t spot it in real time, is to dispatch an aircraft. Each time an aircraft takes off it costs over $8000 before it leaves the ground. If on the other hand, across the nation we were able to monitor the movement of disease states and illnesses across the populations within which we serve, we would be able to say there is an outbreak of pneumonia in babies in particular communities and therefore resources would be able to be dispatched for its prevention, because an outbreak like this is one of the simplest issues to prevent. We could prevent reaching the acuity where such as the child becomes so unwell that the only solution is to send an aircraft to take them back to hospital.

The heritage of the RFDS is founded in being the Flying Doctor in the air. Today we do much more than simply being the Flying Doctor. We are recognising that oral health is an indicator of overall health so we are expanding into dental services. We have long recognised the importance of mental health to a person’s overall health. But still at our foundation are those 68 aircraft that are the platform for our service delivery. Each aircraft costing seven million dollars, each remains a predominant part of the way in which we do our service. It is our hope that in years ahead, when the stability of the broadband network into remote Australia has improved, we perhaps won’t need sixty-six aircrafts. Instead you will see as part of the enabler of our organisation, a reliable and universally accessible broadband system so that we can take advantage of these extraordinary changes that are happening in the way which health care can be delivered into the most vulnerable populations around our country that need them the most.


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